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Reimbursement Issues

Reimbursement Issues

Emergency medicine physician assistants (EMPAs) are invaluable team members who help provide the best possible care for patients in the emergency department. Medicare, Medicaid and most commercial payors will cover services provided by EMPAs, with each payer determining specific credentialing and enrollment policies. There are variations in reimbursement amounts and policies can vary based on specific payors. 

It is essential to understand that enrollment and credentialing are not synonymous with coverage or payment for services. Many payers who do not separately credential PAs will cover their services when billed under the supervising physician's name or the group practice. The same national payer may have different rules regarding PA credentialing and enrollment in different states. Some private payers or Medicaid departments may enroll PAs while others will not.

Non-Medicare payer enrollment policies are made on the local payer level. These policies vary considerably by state.

NPI  | Medicare | Medicaid | “Incident to” Billing |
Hospital-Based Services | Physician Involvement |
MIPS | Critical Care |

National Provider Identifier (NPI) Number

The Health Insurance Portability and Accountability Act of 1996 (HIPPA) mandates that each health care provider have their own unique identification number. The NPI is a 10-digit number used for the administrative functions and financial transactions adopted under HIPPA. PAs may apply for their NPI number by visiting online the National Plan and Provider Enumeration System (NPPES) website or by calling 1-800-465-3203.

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Medicare covers services provided by EMPAs at 85% of the physician's fee schedule. Each PA must obtain their own NPI number. EMPAs and their employers need to understand Medicare's requirements related to PAs.  

Physician assistants wanting to enroll to be a Medicare provider must meet the following requirements:

  • Graduated from a PA education program accredited by the Accreditation Review Commission on Education for the Physician Assistant.
  • Passed the national certification examination of the National Commission on Certification of Physician Assistants (NCCPA).
  • Licensed by the State in which he or she is practicing.

Information about provider enrolment in Medicare can be found here.

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Medicaid programs are administered by each state and the state determines the extent in which a physician assistant can be reimbursed for services. All states currently cover the services provided by PAs through Medicaid's fee-for-service or managed care plans. Billing for those services does vary from state to state. However, the services are typically reimbursed at the same or a lower rate than that of a physician.

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"Incident to" Billing

"Incident to" is a Medicare term used to describe services billed in the office or clinic setting and therefore is generally not applicable to patients seen in the emergency department.

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Hospital-Based Services

PAs working in the emergency department may bill under their name, and NPI number for evaluation and management (E/M services) reimbursed at 85% of a physician charge.

A “shared visit” allows for billing under the physician's name for reimbursement at 100%. In order to qualify for a “shared visit” according to Medicare policy, there are several specific elements that must be met. The physician must “provide any face-to-face portion of the E/M encounter with the patient” and must perform “a substantive portion of an E/M visit,” defining “substantive portion" as all or some portion of the history, physical or medical decision-making components of an E/M service. The PA and the physician must have the same employer and see the patient on the same calendar day. There also needs to be clear documentation in the patient’s chart regarding the PA and the physician's involvement.  

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Physician Involvement

The Centers for Medicare and Medicaid Services (CMS) has deferred defining the collaborative relationship between physicians and PAs to individual state law. The level of collaboration is variable state to state and is evolving to define more collaborative PA utilization approaches. Medicare does not require that the physician be physically present in the ED. The collaborating physician is ultimately responsible for the medical services and procedures performed by the PA.

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In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA). Beginning January 1, 2017, it instituted the Merit-Based Incentive Payment System (MIPS). This program combined the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VM), and the Medicare Electronic Health Record Incentive Program into a single payment program designed to determine Medicare payment adjustments. With the Merit-Based Payment System (MIPS), providers/hospitals are evaluated on how well they meet specific measures. Failure to meet MIPS thresholds will result in a reduction in reimbursements.

Reimbursement amounts are based on MIPS performance two years prior. This took effect in 2019 with an impact of +/- 5% and increased yearly to a max of +/- 9% in 2022 based on performance. Using a composite performance score, eligible clinicians (ECs) may receive a payment bonus, a payment penalty, or no payment adjustment. 

Further information regarding MIPS can be found here

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Critical Care

Critical care services may be provided by qualified EMPAs and applied for payment using their NPI number. The critical care services must be within the scope of practice and licensure requirements for the state in which the EMPA practices. Critical care time must be billed for each provider and cannot be combined with the time of the collaborating physician's service.

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Every effort was made at the time of publication of the accuracy of this information. This should not be considered an exhaustive discussion of billing requirements or policies, as these requirements can change frequently. This information should not be regarded as legal advice. It is the responsibility of providers and billing entities to understand and correctly interpret billing policies and regulations.

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